The death of a brilliant Lower Earley student who threw herself in front of a high-speed train after becoming stressed over her studies could not have been avoided, a coroner ruled on Wednesday.

“Perfectionist” Chandni Nigam, who achieved straight-As in her exams, was terrified of being forced to take medication having spent six years battling demons which spawned from an obsession to do well at school, an inquest into her death was told.

Miss Nigam, who was aged 19 years when she died, would stay up late studying, resulting in sleep deprivation and consequently a negative impact on her performance at school, culminating in further depression and anxiety.

She was also worried about her appearance, having suffered from problems including acne and hair loss.

Tragically, the teenager – a volunteer at the London 2012 Olympics – told her parents she was suicidal, spelling out how she would stand in front of a fast train on a Tuesday – the way in which she finally died.

However, a coroner said that not even her own father had believed she would go through with the act and that mental health professionals could not have done any more to prevent her death.

Miss Nigam saw numerous doctors over several years but her father told the inquest how she often refused treatment and he felt he was “torturing” his daughter by making her attend appointments, eventually accepting she would one day kill herself.

On Tuesday, February 4, 2014, she was struck by a train travelling at Twyford railway station.

Witnesses described seeing Miss Nigam standing expressionless in front of the approaching train with her arms spread apart.

Chandni’s fears listed

The coroner was told that she had listed three factors which she felt would lead her to take her own life – college, being made to take medication and being forcibly admitted to hospital.

The youngster feared having to go into a psychiatric hospital after being told by a mental health worker that they were “scary and dangerous places full of ill men” and that she felt the authorities were trying to manipulate her father into forcing her to undergo a mental health assessment.

She felt that he had “had the power to enforce two of those three criteria” after overhearing him talking to doctors about the mental health act, the hearing was told.

She had been rushed to AE just days before her death after being spotted at the very same station where she died in an “agitated state” – however her mental health workers were never told about the episode.

Criticism of record keeping

A serious incident review sparked by the teenager’s death criticised the Royal Berkshire NHS Trust for “silo thinking” after it emerged that the mental health experts treating her had not accessed her historical medical records.

The report also slammed the body for “inconsistencies” in her care and ruled that there had been “little rationale given” for the decisions her clinicians reached.

Berkshire Coroner Peter Bedford confirmed that he will write to the Government urging a review of how medical records are shared in such cases.

However he dismissed many of the other criticisms contained in the report, saying: “The reality was that Chandni feared the side effects of medication. If her parents couldn’t persuade her to take it, what chance did the clinicians have?”

Helen Mackenzie, the trust’s director of nursing who commissioned the review, replied: “Chandni was an articulate, bright young lady who knew what she wanted.”

No history of self harm

Recording a narrative verdict, Mr Bedford said: “I can record that Chandni died on the 4th of February 2014 on the railway lined at Twyford Station from multiple injuries, suffered when she deliberately placed herself in front of a train travelling at high speed with the intention of ending her life.

“Further, that Chandni suffered from anxiety and depression with suicidal ideation requiring intervention from the mental health team over a period of time for her complex and longstanding problem.

“Further, that she also suffered a number of physical symptoms including hair loss, exhaustion, sore skin and acne and obsessions about nutrition that significantly affected her.

“Further, that there was an ongoing difference between Chandni’s parents’ views of her risk and the professionals’ assessment on a background of contradictory information from Chandni and her parents as to Chandni’s suicidal ideation and intentions.

“Chandni had no history of significant previous self harm and was never considered by her treating professionals to require sectioning under the mental health act.

“Chandni consistently refused to take prescribed medication recommended by her treating clinicians while having capacity to decide what treatment she preferred.”

He then added: “It seems to me that if Chandni’s family did not predict it happening on the 4th of February, I fail to see how the mental health professionals could have been expected to prevent the events. It seems there’s an overwhelming consensus of opinion that Chandni’s death was not expected.”

On the first day of the three day inquest in Reading, her father, Ankush Nigam, had told the coroner: “I’m glad she’s in a peaceful place.”

Mr Nigam said his daughter first started showing signs of depression and sleep deprivation aged 13 years and visited numerous doctors and was put on various medications over several years.

The inquest heard her doctors believed Miss Nigam showed improvement when on medication, but she was often reluctant to take it.

However, Mr Nigam slammed doctors for not believing him and his wife that their daughter’s condition was worse than she presented to health teams.

He said their concerns were not taken seriously, even when they explained she had told them how she would kill herself.

Mr Nigam said his daughter first spoke of committing suicide by standing in front of a train in October 2013, saying she knew the times of fast trains and that it would be on a Tuesday.

“She clicked her fingers and said it would be instantaneous so don’t worry,” he said.

The inquest heard she told doctors she did not want medication for her condition and was not judged to be a suicide risk.

A family’s pain

Mr Nigam said he began to accept there was nothing that could be done to help his daughter, believing he was “torturing” her by taking her to see medical teams.

He said: “Nobody was willing to accept our version of events. What she said was given so much significance while what we said was ignored.

“I thought I might as well just let her go.

“I was waiting for something like this to happen. I literally felt like a passenger.

“I wish I had not subjected her to any of those doctors or anybody now. All I have done is added to her misery.”

Mr Nigam said every time he dropped his daughter off at a train station he feared it would be the last time he saw her.

He said his daughter eventually killed herself because she feared she would be put back on medication.

The inquest heard Miss Nigam suffered from numerous conditions over several years in addition to her depression, including acne, malnutrition, hair loss and itchy skin.

Miss Nigam, who achieved all A and A* grades at GCSE level, was in and out of school and college as she battled her illness.

Health professionals told the Berkshire coroner Peter Bedford that school and college work affected Miss Nigam’s state of mind, but she did not appear to need hospital treatment.

In September 2013 the star pupil began studying at Henley College, but Heather Jewitt, a mental heath nurse with the Berkshire Healthcare NHS Foundation Trust, said it was stressful for her.

In a statement read to the inquest, Ms Jewitt said: “She had started college and felt everything was falling apart and she was unable to do her work.

“She said she wanted to die but was adamant she would not act on her thoughts.”

Rebecca Brown, representing Miss Nigam’s family, said: “The family has been left devastated at the death of their beloved child.

“She had been receiving treatment for mental health problems for several years and her parents are seeking answers as to exactly what happened to their daughter and whether anything more could have been done to prevent her death.”

The family declined to comment at the end of the inquest.